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The murders of three elderly women are linked to a home-nursing facility where the owner, Matt Spevak, is considered a suspect. But when Matt is found murdered during the investigation, the SVU squad turns their attention to Matt's sister, Emma, who is a nurse that might be responsible for not only the death of numerous elderly women, but her own mother as well. Emma was supposedly strangled by Matt who was then supposedly killed in self-defense by a woman who then had a stroke, but Warner discovers evidence that the woman was injected with air that caused the stroke. The only other possible suspect is his sister Emma (who was supposedly strangled by Matt before he died), who they believe murdered her mother in the same way as she killed the latest victim, out of jealousy over the affection she gave her brother rather than her. Huang believes the rest of the murders were committed as revenge on her mother.

The mother's body is exhumed and from the gravestone, which has the names and birthdates of all of the family. The detectives learn that Emma and Matt are actually fraternal twins. Huang figures that Emma has always been in Matt's shadow as she's the younger twin and the rope she used to murder the women was a sign of that. Warner's autopsy proves that the mother was murdered as she has the same puncture mark as the last victim, but they don't have enough evidence to charge Emma so at Huang's suggestion, Stabler and Benson act like Stabler is very bossy and demanding of Benson like Matt was to Emma and Benson pretends to sympathize with Emma to get her to confess: Emma's mother was dying of cancer for five years and Emma took care of her. She killed her to end her suffering while her brother was in medical school. She reveals that there's more than five victims (six with Matt): there's dozens who she doesn't know the names of. She murdered them with air embolisms while she was going to school and all she knows of their names is that they were called "Mama."